Question: Years ago I made a document saying I didn’t want extreme measures in the event of accident or injury. Now I’m wondering, with this virus, would that keep me from getting a ventilator if I became infected?
Answer: No. To be clear, we are assuming that you completed a standard Advance Health Care Directive. Such a document designates someone to speak for a patient who cannot speak for themselves. It does not dictate emergency medical treatment and would not prevent you from receiving warranted, available intensive care, according to the medical and legal experts we consulted. It would express end-of-life wishes if the standard of care proved unsuccessful and your chance of recovery was slim.
Kokua Line has received numerous similar questions amid the COVID-19 pandemic — some from healthy people like you, who want every possible treatment should they fall ill, and some from frail readers with a different point of view, who would prefer to stay out of the hospital altogether.
In either case, and regardless of the pandemic, it’s important that these readers and others share their thoughts with loved ones; decide who should speak on their behalf if the time comes; and draft, review or update an Advance Health Care Directive spelling out their wishes. In addition, people in failing health may want to have Physician’s Orders for Life-Sustaining Treatment.
The AHCD is a legal document that people can draft on their own or with the help of an attorney, while the POLST is a medical order that must be authorized by a doctor. While it’s recommended that all competent adults have an AHCD, only those who are seriously ill or frail also need a POLST, which dictates specific medical orders, such as whether or not to resuscitate.
“So long as a patient can speak for themselves their voice guides care. We only use POLST and AHCD when the patient is unable to speak for themselves. In the case of the POLST, to direct care in an emergency situation and in the case of the AHCD to let doctors know who the patient’s trusted spokesperson (agent) is and to provide some general guidance to the agent and doctors regarding the patient’s philosophy of care when recovery is not expected,” Dr. Daniel Fischberg, medical director for the Pain and Palliative Care Department at The Queen’s Medical Center, said in an email.
“While a POLST can be used to designate DNAR (Do Not Attempt Resuscitation) status in the community, it is also possible to use the POLST to document a preference to receive a resuscitative attempt (CPR). … That’s what many of us like about the POLST form: it allows people to individualize their treatment preferences for an emergency situation when they may not be able to speak for themselves,” he said.
By contrast, “the Advance Directive does not direct care in this situation because it is not a medical order. The directive empowers a spokesperson and guides the direction of care when life-prolonging treatments are failing or recovery to an acceptable quality of life (as defined by the patient) is no longer believed to be medically possible,” he said.
About 36% of Hawaii adults have an AHCD, a percentage that rises to 50% among those over age 50, said Jeannette Koijane, executive director of the nonprofit organization Kokua Mau, a hub for advance care planning.
Kokua Mau, which means continuous care in Hawaiian, has Advance Health Care Directive forms available for download on its website, kokuamau.org, along with a wealth of information to help families navigate these crucial conversations.
“Now, because so many people are at home, it might be a good time to have these conversations, not because there’s a pandemic, but because people are together” and available to think deeply about what they value in life, which can guide their decisions about end-of-life care, said Koijane.
The website also has a guide to decision-making specifically about COVID-19, which asks people to think about what would matter most to them if they became seriously ill with the disease. Would they want to be made comfortable, or would they want every possible treatment? Would they want to go to the hospital and receive intensive care? Or would they rather stay home? Are they worried about being alone? Who or what are they relying on through this difficult time?
It’s a difficult subject to ponder, but an essential one nonetheless.
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